Adequate formal training in minimal invasive surgery, preferably during
post graduation or alternatively as an observer but not merely by attending workshops over weekends
Proper selection of initial cases - thin built female patient with short history of biliary colics only, no history of acute cholecystitis, thin walled distended gall bladder on ultrasound
Proper informed consent (including chances of conversion and higher risk of bile duct injury)
Good quality equipment and instruments
Proper cleaning and sterilisation of instruments
A qualified and trained surgeon as the first assistant
Urinary bladder evacuated just before anaesthesia and surgery
General anaesthesia
Open insertion of first canula
30° telescope
All instruments must be introduced, operated and removed under vision
Fundus retracted upwards towards right shoulder
Gall bladder neck retracted down and out
Remember that every patient has his/ her own biliary and vascular anatomy in the Calot’s triangle
Cystic lymph node is an important landmark – keep to its right
No cautery in Calot’s triangle – it should be used in gall bladder bed only
Suction canula is a good instrument for blunt dissection
Hug the gall bladder, not the bile duct
Clipping of the cystic duct flush with the common bile duct is not required
It is safer to leave a few mm of cystic duct than to encroach even 1 mm on the common bile duct
Double clips on the retained side of the cystic duct and cystic artery
Ligature, Haemoclip, Endoloop and stapler are useful devices to tackle a
wide cytic duct
Normal sized common bile duct can easily be mistaken for cystic duct
Beware of wide cystic duct, long cystic duct, vertical cystic duct – it may
be common bile duct
Very soft (normal) liver, fatty liver and cirrhotic liver can easily be injured
during retraction
Fundus first is a useful technique in difficult cases
Partial cholecystectomy is an option in case of difficulty
Panic should be avoided in case of bleeding
Pressure with a gauze or the mobilised gall bladder will control the bleeding or make it controllable
Desperate blinds attempts to clip or coagulate a bleeding point in a pool of blood must be avoided
Stumps (cystic duct/ cystic artery) should be examined and re-examined for security of clips and any bile leak/ bleed
Gall bladder bed should be irrigated and examined for any bleed/ bile leak (from a cholecysto-hepatic duct)
Presence of bile should make the surgeon stop and look for the source of bile - gall bladder or bile duct
Extraction of gall bladder under vision to make sure that there is no bile/
stone spill
Spilled bile should be sucked out
Spilled stones should be looked for and removed
Aponeurosis at 10 mm port sites should be closed
Surgeon should not have any ego to complete every cholecystectomy
laparoscopically
Conversion is a safety valve and an emergency exit
Have a low threshold for conversion
Conversion is not a failure on the part of the surgeon
Cholecystectomy should not be considered a small/ routine operation and should not be taken lightly/ casually
Surgeons should avoid the temptation to get their names into books of
records
Experience is no protection against bile duct injury
All gall bladders, even if they look grossly normal, should be sent for
histopathology so as not to miss an incidental gall bladder cancer
The day after cholecystectomy, the patient should be without pain, sitting up in the bed, having her breakfast and wanting to go home – vitals should be stable/ normal and abdomen soft; if not, observe the patient in the hospital for another day
In the era of increasing medical litigation, a safe cholecystectomy is safe